A qualitative assessment of Ukraine’s trauma system during the Russian conflict: experiences of volunteer healthcare providers

Background The Russian Federation’s invasion of Ukraine is characterized by indiscriminate attacks on civilian infrastructure, including hospitals and clinics that have devastated the Ukrainian health system putting trauma care at risk. International healthcare providers responded to the need for help with the increasing numbers of trauma patients. We aimed to describe their experiences during the conflict to explore the gaps in systems and care for trauma patients to refine the Global Trauma System Evaluation Tool (G-TSET) tool. Methods We conducted qualitative key informant interviews of healthcare providers and business and logistics experts who volunteered since February 2022. Respondents were recruited using purposive snow-ball sampling. Semi-structured, in-depth interviews were conducted virtually from January-March 2023 using a modified version of the G-TSET as an interview guide. Interviews were transcribed verbatim and deductive thematic content analysis was conducted using NVivo. Findings We interviewed a total of 26 returned volunteers. Ukraine’s trauma system is outdated for both administrative and trauma response practices. Communication between levels of the patient evacuation process was a recurrent concern which relied on handwritten notes. Patient care was impacted by limited equipment resources, such as ventilators, and improper infection control procedures. Prehospital care was described as highly variable in terms of quality, while others witnessed limited or no prehospital care. The inability to adequately move patients to higher levels of care affected the quality of care. Infection control was a key issue at the hospital level where handwashing was not common. Structured guidelines for trauma response were lacking and lead to a lack of standardization of care and for trauma. Although training was desired, patient loads from the conflict prohibited the ability to participate. Rehabilitation care was stated to be limited. Conclusion Standardizing the trauma care system to include guidelines, better training, improved prehospital care and transportation, and supply of equipment will address the most critical gaps in the trauma system. Rehabilitation services will be necessary as the conflict continues into its second year. Supplementary Information The online version contains supplementary material available at 10.1186/s13031-024-00570-z.

102.5 -Military medical Roles of Care established and medical units are trained and assigned to their respective roles of care (MILITARY ONLY) 103 -Establish communication within the system leadership 103.1 -System wide key leader meeting held at least quarterly (political, military, and medical key leaders to discuss status of the system) 401.1 -Establish a lead, highest level of care, trauma center.401.2 -Establish a lead trauma provider (physician, nurse, other trained trauma provider) for each trauma center 401.3 -Establish clearly defined role for each trauma center within the system with its designated capability for level of care based on resources, equipment, supply, and personnnel 401.4 -Facilities are included in the trauma system (and written into the trauma system plan) from the district hospital/clinic initial care and stabilization level to the best capability hospital center for the State/Nation/Region. 401.5 -Each medical facility lead agent has designated authority by the medical facility leadership.402 -Establish transfer agreements and understandings between trauma care facilities of the lowest to the highest capability to facilitate patient movement within the system to the appropriate level of care in a timely fashion.501.1 -Establish a lead, highest level of care, trauma center.This trauma center should be capable of providing the full spectrum of trauma care services from initial care through rehabilitation.It should provide full leadership within the system for all trauma care centers under the overall trauma system leadership.
501.2 -Establish a lead trauma provider (physician, nurse, other trained trauma provider) for each trauma center 501.3 -Establish clearly defined role for each trauma center within the system with its designated capability for level of care based on resources, equipment, supply, and personnnel 501.4 -Facilities are included in the trauma system (and written into the trauma system plan) from the district hospital/clinic initial care and stabilization level to the best capability hospital center for the State/Nation/Region.

402. 1 -
Transfer agreements between all levels of initial care are established 402.2 -Methods of transfer between all levels of initial care established 402.3 -Ensure all level of trauma facilities are integrated into disaster and mass casualty plans.403-Establish Trauma facility data collection and use403.1 -Each trauma facility collects data and contributes data to the system.403.2 -Each trauma facility receives feedback based on evaluation of trauma data from the trauma system leadership.404 -All trauma facilities have evaluations completed for their initial trauma care areas.404.1 -Complete assessment of the initial trauma and emergency care for each facility in the system (WHO Needs Assessment and Evaluation Form for Resource Limited Heatlh Care Facility and WHO Essential Emergency Equipment List and WHO Anesthesia evaluation) lead agent for Trauma Center (For facilities providing both initial trauma and emergency care but also referral/tertiary care or ongoing/complete trauma care)

Initial Injury Care (District and Regional Hospitals/clinics) (400)
Establish overall Trauma and Emergency Medical Director for command,  control, and communication (patient movement decisions and mascal C3); this includes a centralized command post and bi-directional communication capability 104.5 -Establish communication plan with police, fire, military, other agencies that react to disasters or mass casualty incidents Establish legal authority for lead agent for system injury and emergency prevention issues 201.2 -Lead Agency and agent is clearly designated 201.3 -Lead Agency/agent receives data from other components and trauma registries 201.4 -Lead Agency/agent has direct communication with trauma and emergency system leadership and attends system meetings at all levels 201.5 -There is a lead agent for battlefield and non-battle injury prevention initiatives and this agency/agent has a direct route to military command leaders for implementation and evaluation of initiatives (MILITARY ONLY) Establish written policy for pre-hospital care in the Nation/State/Region 302.2 -Establish pre-hospital care at scene plan 302.3 -Establish pre-hospital provider standards of care.Regardless of type of prehospital provider used, lay person or trained medical personnel, standards of care should be established.302.4 -If lay person care is intended in this phase of care, there should be a link to the leadership arm of the system in order to provide awareness and education to the population and to create laws enabling lay person responsibility and care.
104.1 -Establish radio communication between roles of medical care and a centralized battlefield Trauma System Director, a centralized command facility, and the ability for bi-directional communication (MILITARY ONLY) 104.2 -Establish communication between medical field assets (vehicles and personnel) and medical facilities 104.3 -Establish communication between medical facilities 104.4 -107 -Lead Agents of each component adopt trauma system standards of care at each level 107.1 -Public Health (political and medical) leadership establish standards of care for hospitals and other components of system 107.2-Component leaders develop standards of care for pre-hospital provider care (EMT B, etc), hospital care (level of hospital responsibility for trauma care based on capability of that facility), transfer guidelines between facilities, triage guidelines for pre-hospital care, data collection and 202 -An Injury Prevention Program is established for Nation/State/Region 202.1 -Received data is analyzed on a frequent, no less than quarterly basis, to identify prevention interventions 202.2 -Prevention agency has identified and implemented at least one high yield prevention intervention for the system 202.3-Prevention agency seeks ongoing feedback from registries regarding effectiveness of prevention interventions 202.4 -Prevention agency seeks cooperation and collaboration with other medical agencies and with public health officials and community leadership as available 202.5 -Prevention agency integrates prevention into the national trauma COMPONENT: Establish standards of education for each level of provider 702.3 -Establish method of assessing compliance at each clinical level 702.4 -Each trauma center has lead agent and plan for education 703 -Establish Research lead agency 703.1 -Establish a plan for research for the system and for each center 703.2 -Develop and implement an injury database 703.3 -Ensure each trauma center collects data for all trauma patients 703.4 -Ensure each center contributes data to the system database on an established schedule (ie monthly, bimonthly, etc) 703.5 -Ensure Research agency also collects and analyzes population-based data in conjunction with efforts of Prevention Agency 703.6 -Agency analyzes data from system on a routine basis to assess for gaps in care and areas of potential improvement 703.7 -Agency informs system leadership regarding gaps in care based on injury data and population data and makes recommendations for system and trauma center improvement based on this data 704 -Establish lead agency for QI 704.1 -Each trauma center establishes lead agent/agency for QI 704.2 -System establishes overall lead agent/agency with authority to direct hospital QI and system QI 704.3 -QI agents work with Prevention agents and Research agents in order to identify gaps in care based on collected data 704.4 -QI agents work with Prevention agents and Research agents in order to develop interventions for improved care within centers and the trauma system based on identified gaps